Epiglottitis
Pathophysiology "Epiglottitis is inflammation of the epiglottis caused by a bacterial infection of the upper airway. Although uncommon, epiglottitis can progress rapidly and become life threatening. It can occur at any age. (The Harriet Lane Handbook suggests that epiglottitis most often effects children from 2-7 years old1) The disease usually is associated with Haemophilus influenzae type B, but Streptococcus, Pneumococcus, and Staphylococcus organisms also have been implicated. The bacterial infection causes edema and occlusion from swelling of the epiglottis and supraglottic structures (pharynx, aryepiglottic folds, and arytenoid cartilage). Epiglottitis is a true emergency." 2 -''Mosby's Paramedic Textbook'' Clinical Presentation "Patient is usually febrile, anxious, and toxic appearing, with sore throat, drooling, respiratory distress, stridor, tachypnea, and tripod positioning (sitting forward supported by both arms, with neck extended and chin thrust out). Any agitation of the child may cause complete obstruction, so avoid invasive procedures/evaluation until airway is secured." 1 Epiglottitis often develops overnight in a child who was appearing perfectly healthy beforehand. Onset of fever is sudden and high grade. Drooling is a late sign, indicating that swallowing is so painful that the child is no longer doing so. While any child with epiglottitis is at risk for airway compromise, one that can no longer swallow properly should be considered especially severe.2 Prehospital Management 1) Blow-by oxygen in the most unobtrusive fashion possible.1 Keep the child with their parent if possible and continue to maintain position of comfort that the child favored upon arrival.5 2) Alert the hospital of the emergency, giving them time to assemble the pediatric team that will need to be present upon arrival. This is to be treated like a Code STEMI or Code Stroke would.1 3) Be prepared to provide BVM therapy and intubate the patient. Medical direction may indicate the use of an uncuffed tube that is 1-2 sizes too small to facilitate passing the inflamed epiglottis. If respiratory failure occurs, the patient may be able to be bagged even if the airway appears to have closed. If bagging is no longer possible, intubation and cricothyrotomy are the next two options.2 4) Once the patient is intubated, establish vascular access.5 5) SoluMedrol 2 mg/kg IV, max 125 mg(6) or Dexamethasone 0.3 to 0.6 mg IV, IM, or PO once (effects last 2-3 days)(1) Intubation in Epiglottitis Mosby's paints a bleak picture of intubation in the pediatric epiglottitis patient... "Intubation may be difficult because the vocal cords are likely to be hidden by swollen tissues. (An uncuffed endotracheal tube one to two sizes smaller than normal may be recommended by some medical direction physicians.) The paramedic should locate the opening to the larynx by looking for mucous bubbles in the cleft between the edematous aryepiglottic folds and the swollen epiglottis. (Chest compressions during glottic visualization may produce a bubble at the tracheal opening.) In the rare instance that intubation cannot be achieved and the child cannot be ventilated adequately by a bag-valve device, medical direction may advise needle cricothyrotomy. Often a child’s lungs can be ventilated through the occlusive crisis of epiglottitis by bag-valve-mask ventilation using a tight facial seal. This may call for two persons—one to maintain the seal and the other to ventilate." 2 Fiberoptic imagery of a edematous epiglottis during a retrograde intubation attempt References 1) Engorn B, Flerlage J, eds. The Harriet Lane Handbook, 20th ed. Philadelphia, PA: Elsevier Saunders; 2015. 2) Sanders MJ. Mosby’s Paramedic Textbook. Burlington, MA: Jones & Bartlett Learning; 2012. 3) Hammer GD, McPhee SJ, eds. Pathophysiology of Disease - An Introduction to Clinical Medicine, 7th ed. New York, NY: McGraw-Hill Education; 2014. 4) Broaddus VC. Murray and Nadel’s Textbook of Respiratory Medicine. Philadelphia, PA: Elsevier Saunders; 2016. 5) Cline DM, Ma OJ. Tintinalli’s Emergency Medicine: Just the Facts, 3rd ed. New York, NY: The McGraw-Hill Companies, Inc.; 2013. 6) Caroline NL, Elling B, Smith M. Nancy Caroline’s Emergency Care in the Streets, 7th ed. Burlington, MA: Jones & Bartlett Learning; 2012